Continuous variables were shown as mean ± standard error, and the differences among each group were compared by Kruskal-Wallis one-way analysis of variance followed by Student t test. Categorical variables were analyzed by Fisher exact test. A P value of < .05 was considered statistically significant. Statistical analysis was performed with JMP 9.0 software (SAS Institute Inc, Cary, NC). Transgastric access to the peritoneal cavity was successfully created in all dogs with a mean time of 5.0 ± 0.4 minutes. Peritoneoscopy revealed no access-related damage to the adjacent organs

and abdominal wall. Gastrotomy closure was easily achieved in groups B, C, and BLZ945 supplier D, with a similar average procedure time (5.8 ± 0.4 minutes, 6.2 ± 0.4 minutes, and 6.3 ± 0.6 minutes, respectively). In contrast, closure by endoclips (group Galunisertib A) appeared to be more time-consuming, especially for the large, gaping defects, as shown by significantly longer closure time (35.4 ± 1.9 minutes) than the other 3 groups (Table 1,P < .001). Accordingly, more

clips were needed for the gastrotomy closure in group A (7.3 ± 0.5 clips) than in group B (3.0 ± 0.1 clips, P < .001). In group C, one OTSC clip was sufficient to close the gastric opening in each of the 10 cases. As shown in Table 1, the leakage tests using explanted stomachs revealed a mean leakage pressure of 81.5 ± 2.1 mm Hg in the OTSC closure group and 87.0 ± 3.0 mm Hg in the hand-suturing group, significantly higher than the omentoplasty group (42.2 ± 4.1 mm Hg) 17-DMAG (Alvespimycin) HCl or endoclip group (34.5 ± 2.6 mm Hg) (P < .001, analysis of variance). No statistical difference was found between the endoclip and OP groups (P = .09). During the follow-up period, 2 of 6 animals (33.3%) in group A had a high-grade fever fluctuating from 38.5°C to 41.0°C 24 hours after NOTES, accompanied by shivering, lethargy, and loss of appetite. The general condition of these two dogs was deteriorating, which was considered to be related to severe infectious

adverse events. At the discretion of the veterinarians, they were killed prematurely with euthanasia on day 7. At necropsy, the gastrotomy sites were found to be unsealed with spillage of gastric contents into the peritoneal cavity, together with purulent peritonitis and extensive adhesions (Fig. 3A, B). The cause of death was therefore deemed to be acute peritonitis secondary to gastric content leakage (Table 2). The remaining 18 animals survived over 2 weeks with no evident clinical symptoms or signs of illness. On day 14, a repeat endoscopy and necropsy after the dogs were killed were performed, revealing good healing and no gross abnormalities in all 18 surviving animals. Over half of the endoclips had dislodged in groups A and B, and the remnant clips were seen attached superficially, no deeper than the mucosal layer.